PMRMD

Another way to identify PICC tip location is with ECG guidance. An ECG signal can be derived from the guide wire or from a saline flushed PICC (e.g., after guide wire removal). The technique is based on the dramatic changes in the P wave as you get within about 4 cm of the caval-atrial junction (see http://www.pacerview.com/index_files/CVC_AND_PICC_TIP_LOCATION_WITH_PACERVIEW.htm). These changes can be seen in real time, at the time of placement. You can also derive a signal from the saline after placement to see if the tip has migrated into the atrium. It's less expensive and faster than x-ray and well established in the literature (see the references page at the PacerView website).

I thought I would mention another way to do tip location in real time - ECG guidance. The principal is that an ECG can be derived from the guide wire of the CVC and the P wave dramatically changes as you get within about 4 cm of the SVC - right atrial junction (see http://www.pacerview.com/index_files/CVC_AND_PICC_TIP_LOCATION_WITH_PACERVIEW.htm). As you'll see from the tracings there, the changes in the P wave are not subtle. The technique is well established (numerous references are cited on the same web site) and accurate, less expensive and less time consuming than x-ray, and a recording of the ECG transitions can be your documentation.